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MEMORANDUM OF SERVICE LEVEL EXPECTATIONS FOR

PART-TIME PHYSICIAN ON ADJUSTABLE WORK HOURS

PRIVACY ACT STATEMENT: The Department of Veterans Affairs (VA) is asking you to provide the information on this form under

the authority of Section 7405(a)(1)(a) of Title 38, United States Code in order for VA to determine the expected level of commitment and

estimate the amount of time a part-time physician is expected to dedicate to patient care, administrative, research, and educational

activities. The information you provide will become part of the "General Personnel Records (Title 38)-VA" (76VA05) Privacy Act

system of records. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use"

disclosure of the information for: civil or criminal law enforcement; litigation in which the United States is a party or has an interest;

Federal or State licensing boards; and personnel administration. Providing this information to VA is voluntary. However, if you do not

provide the information, VA will be unable to employ you as part-time physicians placed on adjustable work hours must complete and

sign a Memorandum of Service Level Expectations.

NAME OF VA FACILITY

FACILITY ADDRESS

FACILITY

STATION NO.

EMPLOYEE AGREEMENT/CERTIFICATION

1. Under regulations issued by the Secretary of Veterans Affairs, hereinafter referred to as the Secretary, I understand that I

am to provide to the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA)

hours of

service during the period beginning

; and ending

. Generally, these

hours are to be divided as follows:

% (patient care),

% (administration),

% (research), and

% (education). I understand I may terminate this memorandum at any time; that my pay and benefits will be

determined in accordance with regulations issued by the Secretary, and that this memorandum does not alter the applicability

of VHA regulations or procedures concerning the terms, conditions, or duration of my employment. It is further understood

that this memorandum does not constitute an employment contract.

2. This memorandum shall be effective upon approval by the Secretary (or designee) of the amount payable, provided I am

otherwise eligible, shall commence on the date prescribed in accordance with regulations.

3. If this memorandum expires or is terminated, the hours of service I have provided and salary and benefits I have received

during the term of this memorandum will be compared. If I have provided service for which I have not been compensated,

VHA will compensate me for such service in accordance with regulations issued by the Secretary or designee. If I have been

compensated for hours of service I have not provided, I understand I am to refund such excess compensation to VHA in

accordance with regulations issued by the Secretary or designee. It is further understood that any amount due on my behalf

will be considered to be a debt due to the United States that I am to pay in full as directed by VA.

4. I understand that this Memorandum of Service Level Expectations terminates when any of the following occur:

a. Separation from VHA employment for any reason.

b. Transfer to another VHA facility.

c. Acceptance of a position that does not qualify for adjustable work hours.

d. Completion of agreed period of service, or enactment of superseding law.

e. Execution of a superseding Memorandum of Service Level Expectations.

5. I acknowledge that VA Directive 5011 and VA Handbook 5011, part II, issued by the unit secretary (or designee) to

implement adjustable work hours, are incorporated into and made a part of this memorandum and I have read a copy.

6. I acknowledge that the unit secretary (or designee) may, pursuant to regulations, adjust the amount of the pay to which I

am entitled to reflect appropriately any change in my basic pay, special pay (if applicable), or position status (e.g., proportion

of part-time employment or change in level of responsibility).

SIGNATURE OF APPLYING PHYSICIAN

DATE SIGNED

APPROVAL SIGNATURE, UNIT SECRETARY OR DESIGNEE

DATE SIGNED

APPROVAL SIGNATURE, FACILITY DIRECTOR OR DESIGNEE

DATE SIGNED

0880a

VA Form

DEC 2006

Va Form 0880a - Memorandum Of Service Level Expectations For Part-Time Physician On Adjustable Work Hours

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